Abstract
Abstract
Background:
Existing research regarding design improvements to the operating room (OR) is scarce and emphasizes the compelling need to measure and test new design strategies and interventions.
Methods:
We propose a conceptual framework for measuring and improving OR physical space design by outlining how two existing measurement schemes can be adapted for ORs. The structure, process, outcomes model described by Donabedian in 1966 is used to show how each of these three measurement approaches can be used to evaluate OR design. In addition, we describe a common design framework that focuses on the end-user experience to highlight the impact different OR stakeholders can have on the prioritization of improvements.
Results:
The structure, process, outcomes model has both benefits and drawbacks for measuring OR design quality. For example, these components are easy to measure, highly actionable when deficient, and have high validity as the bottom line. However, they may not necessarily reflect better quality or correlate to better care, and some need risk adjustment to make comparisons fair. The end-user experience model should account for the needs of patients, OR nurses, anesthesiologists, surgeons, facilities managers, hospital administrators, infection control officers, and regulators, among others.
Conclusion:
The design quality of ORs influences outcomes and determines the quality of experience for multiple stakeholders. Patients, providers, and hospital staff would benefit directly from efforts to improve OR physical space design. By adapting previously established frameworks, it is possible to measure, evaluate, and improve OR design.
O
Recent efforts to improve the design quality of ORs have attempted changes in process design (e.g., faster room turnover) and physical space design (e.g., room layout) [3,4]. Process design has appeal because it allows for multiple intervention points to improve delivery of care. Although promising, most efforts to improve OR-associated processes have been limited by few high-yield target points, difficulty maintaining process changes when personnel turn over, and limited generalizability across multiple service lines. For example, consider the numerous process interventions put forth to improve OR on-time starts. Although multiple efforts have been attempted, OR on-time starts continue to vary widely among institutions [5]. Similarly, efforts to improve the physical space design of ORs have been limited in their impact. In general, the layout of the OR has not changed in decades, and few other physical space design interventions have been tested. The only changes leading to some measurable benefit have been through Lean exercises to improve supply chain and storage elements [6]. Existing research regarding design improvements to the OR is scarce and underscores the compelling need to measure and test new design strategies and interventions [7].
Here, we propose a conceptual framework for measuring and improving OR physical space design by outlining how two existing measurement schemes can be adapted for ORs. First, the structure, process, outcomes model described by Donabedian in 1966 [8,9] will be used to show how each of these three measurement approaches can be used to evaluate OR design. Next, we will demonstrate a common design framework that focuses on the end-user experience to describe the impact different OR stakeholders can have on the prioritization of improvements. Finally, we discuss how OR redesign can be incentivized from the perspective of multiple stakeholders, including patients, providers, policymakers, and designers.
Measuring OR Design Quality Using the Structure, Process, Outcomes Framework
The structure, process, outcomes framework was first described in the landmark Health Affairs article by Donabedian in 1966 [8]. In doing so, he sought to give a vocabulary and framework to understand what so many started to intuit: some patients seem to get better care than others. It has since become the backbone of quality improvement in healthcare and is a deserving starting place to think about the design of operating rooms.
Using structure to evaluate OR design quality has benefits and drawbacks (Table 1). On the one hand, structural elements can be measured objectively because they are usually located in floor plans or existing hospital facility data. As such, using the structure framework can allow for easy comparisons across hospital facilities. In contrast, few true structural measures have been correlated to any known patient outcomes. It is unknown to what extent these structural differences (e.g., OR square footage, door location) explain differences in clinical care. Furthermore, even if benefits were associated with certain structural design, it may be difficult to make these findings actionable. Few hospitals would have the ability or resources to overhaul their OR suites or build new.
Structure, Process, Outcomes Framework to Evaluate Operating Room Design Quality
OR = operating room; HVAC = heating, ventilation, air conditioning.
Process
Process includes the steps involved in preparing and maintaining the OR. Examples include ensuring appropriate ventilation system maintenance, sufficient room sanitation between cases, effective restocking and supply, and appropriate lighting maintenance.
Using process to evaluate OR design similarly has advantages and disadvantages. Advantages include the fact that processes are highly actionable when found to be deficient (e.g., replacing lighting or air filters as needed). However, similar to structural elements, few processes of maintaining an OR have been shown to be associated with improved patient care. Furthermore, these elements are generally considered as up-keep and self-evident that they should be occurring on schedule. As such, there may be difficulty establishing buy-in from end-users to invest substantial resources in better understanding the process of maintaining an OR.
Outcomes
Outcomes are the end result of care delivery. Outcomes of interest vary depending on the priorities of the OR user, but may include a range of elements such as throughput, mortality, surgical site infection rates, room turnover time, and patient satisfaction scores.
Using outcomes to evaluate OR design has broad buy-in because most believe it to be the bottom line to evaluate care delivery. Because outcomes are specific and recognized as important, they have powerful potential to motivate policy changes or become the basis for different interventions. As such, they could be the turning point for improving OR design. That said, using outcomes to evaluate OR design can be challenging. To compare outcomes across ORs fairly, more complex analysis such as patient and surgeon level risk-adjustment may be required to ensure fair comparisons. These types of analyses run the risk of being confusing or misleading if not performed in a standardized manner. Moreover, they are far more resource intensive than simply comparing the process or structural elements of ORs.
Measuring OR Design Quality Using the End-User Experience Framework
The end-user experience framework allows for evaluation of how users of the OR interact with the space. In general, each user will have specific goals for optimizing the space depending on his or her responsibilities and priorities. Table 2 outlines some of the many possible user-centered goals for improving OR design quality. These examples do not represent the views of all people in that category but are meant to be illustrative of how they may be a range of measurables that can be influenced by the design of the OR.
End-User Experience Framework to Evaluate Operating Room Design Quality
Surgical never-events have been defined by the National Quality Forum and include wrong site, wrong procedure, and wrong patient operations [13].
OR = operating room.
Patients
One method to improve the patient user experience may be to maximize comfort during transfers from the pre-operative holding area to the OR table. Common concerns expressed by patients during this transition include distance traveled to the OR and temperature of the room once entered. Patients also report experiencing high levels of stress and anxiety in anticipation of a procedure. A method of measuring the impact of these concerns on patient experience may be through patient experience surveys. Design elements that could be modified to maximize patient comfort include streamlining the route from pre-operative holding to the OR, as well as ensuring the availability of pillows and blankets during the transfer time. In addition, as part of pre-admission testing, patients could be familiarized with the pre-, intra-, and post-operative environments by viewing a virtual tour [10,11].
Operating room nursing staff
For OR nurses and circulators, a priority may be to reduce the number of missing tools or equipment trays during a procedure. One way to measure progress toward this goal would be a simple count of the number of times a staff member places a call to order missing equipment or has to leave the OR to retrieve one of these items. A potential design intervention to reduce the number of these events would be the creation of multi-purpose or adaptable ORs with more storage and stocking options. Planning the overall suite configuration around a clean core and/or providing a case-cart system may also reduce confusion and delay during procedures.
Anesthesiologists
Anesthesiologists often desire improved intra-operative communication with the surgical and nursing staffs, especially as it pertains to patient monitoring. The quality of communication can be measured via lapses in closed-loop communication cycles. To minimize such events, OR design can be modified to reduce ambient noise and increase the likelihood of completing clear verbal communication loops. As part of the mock-up process, the position of the anesthesiologist within the room can be tested and communication connections can be optimized.
Surgeons
For surgeons, visibility is paramount to operative performance. The use of various modalities, including laparoscopic and robotic consoles, to perform procedures means there are many adjustments that are made throughout a case with respect to lighting angles and screen positioning. One potential design quality improvement to reduce the number of adjustments per case may be to automate these lighting and screen angles based on surgeon movements or to include an option for voice-activated control.
Facilities managers
Hospital facilities managers are interested in maximizing efficient room turnover between cases, as measured by the minutes between cases. Because much of the work of cleaning an OR and prepping it for the next case requires the ability to navigate around multiple pieces of equipment, one design intervention to facilitate this could include minimizing equipment on the floor, for example, through the use of hanging ceiling booms, which would allow for faster floor cleaning and improved maneuverability. In addition, implementing modular OR construction systems may provide opportunities to adapt OR environments for surgical innovations, new technology, and regulatory changes after initial construction without substantial capital expense [12].
Administrators
Hospital administrators prioritize maximizing OR volume, as measured by number of cases performed, because surgical procedures provide a substantial portion of hospital revenue each year. Measuring OR percent utilization on a given day or across other time periods is already a common practice. From a design quality perspective, it may be possible to create adaptable ORs that can accommodate multiple procedure types. This would minimize the number of cases that are delayed or postponed because a specific room type is unavailable and would reduce the number of ORs left empty. In addition, universally designed pre- and post-operative holding or observation units can provide flexibility for all types of cases. Co-location of outpatient and inpatient operating rooms would provide opportunities to address surge conditions and accommodate changes in volume resulting from fluctuations in workload.
Infection control officers
Infection control officers focus on reducing infection rates. Surgical site infections, therefore, are an outcome of interest and can be easily tracked using electronic medical record data. A number of OR design improvements to help reduce surgical site infection rates could be implemented, including minimizing door traffic during active operating time and optimizing ventilation systems in the OR. The quality of data for supporting such intervention is still evolving. Nonetheless, the existing work has made it clear that at least conceptually there are compelling mechanisms to link surgical infections to the built environment of the operating room.
Regulators
Finally, healthcare regulators are likely to pay particular attention to procedure safety as a quality metric. One of the most widely used measures to assess surgical safety is the rate of so-called never events, which include performing an operation on the wrong site (e.g., left knee replacement instead of a right knee replacement), performing the wrong procedure, or operating on the wrong patient. Time-out periods during which the patient, laterality, and procedure are confirmed have been adapted widely into practice before performing the initial incision. To improve this practice further, placement of visual cues in the room to facilitate these pre-operative time-outs may enhance the design quality of ORs.
The above list is not meant to be exhaustive, but only to offer examples of how the end-user experience from different perspectives would potentially be measured to assess the quality of the operating room design.
Incentivizing Better OR Design
Improving OR design will require buy-in from many different users and may represent a substantial cost in terms of time and material resources. In fact, this may underscore why substantial changes to OR design have not occurred yet [14]. However, there are several reasons why improvement in OR design is in the best interest of multiple stakeholders.
First, patient preference may be a driver for OR design quality improvement. Patients today have more choices than ever when selecting a hospital for surgical care. This increased opportunity for choice in hospitals could incentivize improved OR design as measured by patient experience surveys or satisfaction ratings. In an increasingly competitive healthcare landscape that includes online reviews and readily available scoring systems, an improvement in OR design could reflect an important signal to patients that their hospital is dedicated to improving their experience.
Enhancement of OR design could also be driven by a desire for improvement in provider experience and performance. It has been widely publicized that physician burnout levels are currently at an all-time high and continue to increase. It is hypothesized that systemic issues including long room turnover time, ergonomic issues, and a loss of autonomy over patient care can contribute to physician burnout. A desire for health systems to improve provider productivity and decrease burnout rates could lead to a renewed effort to improve the environment in which they operate. Hospitals need to attract and retain top talent to staff surgical suites, which also drives the need to improve OR design. Finishes within the suite may help reduce provider fatigue and improve visualization. Staff or physician lounges with distinctly different interior schemes and exterior exposure can provide relief valves to reduce provider burn-out. Previously believed to be low-priority design areas, lounges may take a more central role if helping to ensure providers stay at top performance for operating.
Policymakers have an active interest in improving OR design insofar as improved design may lead to increased patient safety. An intra-operative sentinel event, e.g., retained foreign body, wrong site surgery, can have a lasting and detrimental effect on a hospital system and its local community. Any design intervention that can ensure optimal patient safety would align directly with policymakers' responsibility to ensure access to safe healthcare services.
Finally, designers and architects may be driven to improve OR design as a competitive advantage to attract clients. As clients are under increasing pressure to demonstrate better returns on their infrastructure investments, any measures to an OR design that could translate to improved efficiency, satisfaction, or safety would be coveted. Architects able to connect their design decisions to improved outcomes will be best positioned to attract competitive clients and justify their fees.
Conclusion
The design quality of operating rooms influences outcomes and determines the quality of experience for multiple stakeholders. Patients, providers, and hospital staff would benefit directly from efforts to improve OR physical space design. By adapting previously established frameworks, it is possible to measure, evaluate, and improve OR design.
Footnotes
Author Disclosure Statement
No competing financial interests exist.